SAFER-SEX PANIC

By Joseph Sonnabend, MD and Richard Berkowitz

Although it is uncertain whether a second wave of AIDS is occurring now, it is clear that the possibility of such an event must concern all of us. There has been a substantial reduction in HIV seroconversion rates since the early days of the epidemic.

Even those who advocate an end to sexual promiscuity as a response to a second wave acknowledge this decline; after all, a second wave implies that the first wave has subsided. However, they attribute the fall in seroconversion rates to a saturation of the AIDS-susceptible population and the second wave to a presumably delayed influx of new susceptible individuals.

They appear to believe that the introduction and practice of safer sex has played no significant role in curbing the epidemic. However, the striking reduction of all sexually transmitted diseases among gay men and the correlation of reduced HIV transmission with the adoption of safer-sex practices found in many studies attest to the success of safer sex.

For example, in Washington State, 658 cases of rectal gonorrhea were reported in 1982, while there were 49 cases in 1996. In San Francisco, over 4,000 cases of rectal gonorrhea were reported each year between 1976 and 1982; the numbers in 1993 and 1994 were 66 and 57. In New York City, there were only about 30 cases reported for both 1995 and 1996, a remarkable drop from approximately 2,000 cases reported in 1982.

However, in some cities these encouraging trends are no longer being sustained. Increases in the incidence of gonorrhea among gay men were reported in several large cities in 1995 and 1996. Interestingly these increases were not reported for New York City, but sadly, we must admit that such increases may well be occurring here now. This is a tragic turn of events. Anecdotal accounts suggest that gay men are now relaxing their safer sex practices, and this is the worst time to be inundated with messages that safer sex cannot work.

Further evidence that safer sex can work is provided by the Multi-center AIDS Cohort Study (MACS) which followed 3,262 initially seronegative gay men; by the end of five years about eleven percent had become HIV seropositive. Black, Latino and young gay men were at higher risk than older white men. Such differences are highly suggestive that safer-sex education can work, as those showing the greatest risk are the ones least likely to have been reached by it.

The efficacy of consistent condom use in reducing HIV transmission has been shown in numerous studies of gay men, female sex workers and HIV-negative partners in serodiscordant couples, both gay and straight.

The contention that safer sex cannot work is not only wrong, it is dangerous. The condemnation of promiscuity and the promotion of monogamy as the only way to save the lives of future generations of gay men could in fact be the greatest threat to their health. This advice rests on a belief that safer sex does not work, and consequently, efforts at intensive targeted safer-sex education could be undermined and even discouraged, as they will be seen as a license to promiscuity.

Monogamy is not a workable option for some nor is it the choice for many others. If the opponents of sexual promiscuity have their way, those who cannot or choose not to heed their message will be deprived of safer-sex education so essential to keeping them alive.

Ironically, in 1983, before the introduction of safer sex, we, along with the late Michael Callen, pointed out the dangers of a way of life that promoted the spread of STDs. We went to great lengths to point out that our attack on promiscuity was not judgmental but based solely on health concerns.

Safer sex changed everything - it has enabled promiscuity - while it is the call for sexual restraint and mono-gamy with its inherent de-emphasis of safer sex that now constitutes the greater hazard to the health of gay men.

Unfortunately, in the prevailing conservative climate, messages condemning promiscuity will have no difficulty being disseminated. Such messages fall neatly into a conservative agenda that places a moral value on sexual restraint. There is a danger that added to the notion that sexual promiscuity is physically unhealthy will be the dreadful implication that it is also morally wrong.

Attacks on sexual promiscuity may therefore not only endanger the health of gay men but also engender a sense of shame and loss of self-esteem. We had come a long way to accepting that sex is one of life's great joys, but the current attacks on sexual promiscuity - even by those who claim to be concerned only with AIDS prevention - may in today's conservative climate undermine this acceptance.

Support of promiscuity must be coupled with demands for greater and sustained targeted safer-sex educational campaigns. This is even more urgent in light of the recent reports of rising rates of gonorrhea among gay men. Sadly, current educational efforts fall far short of what is needed. The most important challenge facing the gay community is the creation of a coordinated effort to produce and disseminate targeted safer-sex educational material to encourage and support gay men in maintaining the practice of safer sex.

An indication of just how urgently these efforts are needed is the recent decision by the federal government to give $250 million to states that implement celibacy campaigns as the means to prevent AIDS among young people. Alarmingly, safer-sex education would be prohibited in programs receiving these funds.

Attempts to control how people choose to express themselves sexually are not new and have always resulted in misery - and now may also promote the spread of AIDS. The most effective way to combat AIDS and prevent a second wave is intensive and well-crafted targeted safer-sex education, not telling people with whom they should or should not have sex.